The Accident Hospitalisation Benefit Explained

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Hospital Cover for Accident Events

Immediate cover
3 Benefit Levels
Nationwide Network
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Mandatory Benefit

Accidents happen, you don't plan for them but you can get a plan that helps cover private hospital costs related to an accident. It even includes rehabilitation treatment, emergency services and emergency casualty cover.

The Hospital Plan has flexible cover for all of this and more.

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Choose Your Level of Cover

Flexible levels of cover mean you get to choose your benefit limits to suit your needs and budget.

Level 1

  • R15,000 per member per year for emergency casualty treatment
  • Single Policies
  • R75,000 per event. R150,000 per year.
  • R2,000 per event for rehabilitation treatment
  • Family Policies
  • R150,000 per event. R300,000 per year.
  • R5,000 per event for rehabilitation treatment

Level 2

  • All Level 1 benefits included
  • Single Policies
  • R125,000 per event. R250,000 per year.
  • Family Policies
  • R250,000 per event. R500,000 per year.

Level 3

  • All Level 2 benefits included
  • Single Policies
  • R200,000 per event. R400,000 per year.
  • Family Policies
  • R400,000 per event. R800,000 per year.

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What is Covered?

All hospital costs related to an accident event are covered within your chosen benefit limits. This includes doctors and radiology like MRI and CT scans. You must be admitted to hospital for 24 consecutive hours for the full benefit to apply.

The only limit for your hospital stay is the chosen benefit limit. You are not limited to a specific number of days in hospital, only the benefit amounts chosen.

Also included in the benefit are:

  • Emergency casualty cover up to R15,000 per member per year. This pays for accident events that are treated in the emergency room and do not result in hospital admission.
  • Rehabilitation treatment up to 12 months after the accident event, limited by the benefit level chosen.
  • 24/7 Emergency Services for rapid response and transport to a hospital.
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Is Pre-Authorisation Required?

In general, all Hospital claims for planned procedures need to be pre-authorised at least 48 hours before you can use the benefit. This is a simple procedure where we determine whether the procedure you need is covered under your benefits and whether you still have available amounts left over after previous claims.

Accidents may require immediate hospitalisation or result in the person affected being unconscious or otherwise unable to obtain pre-authorisation. In these events, medical personal will always stabilise a patient before being generally admitted, at which point your next of kin can assist with identifying you and your available medical cover.

If you can't practically pre-authorise a hospital visit due to an accident then you must inform EssentialMED within 48 hours about the accident event.

The pre-authorisation procedure is described on the Claims page.

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What is an Accident Event?

To quote the policy wording:

  • "A sudden, unforeseen, unusual and unexpected specific event" - an accident
  • "which is unintended" - you didn't mean it to happen and it was not self-inflicted
  • "arises from a source external to the insured" - it was something else that affected you, like a car or a spider
  • "which is independent of illness, disease or other bodily malfunction" - illnesses are not accidents
  • "occurs at an identifiable time and place" - you can pinpoint what it was and when it happened

The definition above helps because it is not only car accidents that apply but also falling, getting bitten by a dog, malaria or other accidental events. But getting cancer, although not intended, is not an accident.

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How does this relate to the Illness Hospitalisation benefit?

The Accident Hospitalisation benefit is designed to offer generous cover for the treatment of all medical costs related to an accident event.

The Illness Hospitalisation benefit is designed to offer cover for hospital costs that are not related to an accident. You cover can be increased by adding in optional benefits like ICU cover, Dread Disease cover and Maternity cover.

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A Network You Can Depend On

Access private healthcare when you need to see a doctor, visit a dentist, get medication or go to hospital.

Nationwide Network of Doctors & Dentists
Private hospitals across South Africa

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Simple & Efficient Claims

Find out how the claims process works for rapid and pain-free claims handling.

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No upfront payments
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Claims paid directly to providers
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Answers to Your Questions

Is there a waiting period for the Accident Hospital benefit?

There is no waiting period. Accidents are covered immediate from the inception date of your policy.

Where I can find the network hospitals?

The benefit doesn't have a specific hospital network and is designed to work with all major hospital groups. The Network page has all the information needed.

How are claims paid?

Claims are paid directly to the medical providers. You can find all the details on our claims page.

What are the age limits?

All new members joining a policy must be younger than 65 years on date of application.

Child dependants must be younger than 21 years before they will need to start their own policy.

However, if your child is still a registered full-time student and unmarried, then they may stay on the policy as a child dependant until they turn 26.

How many people can be on a policy?

Episodic health insurance policies can include:

  • you
  • your spouse/partner
  • up to 6 children